Community Care Licensing

Document Has Been Signed on 08/21/2023 02:53 PM - It Cannot Be Edited

FACILITY NAME:	YERBA BUENA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496801807
ADMINISTRATOR:	MARTINEZ, ANGELICA		FACILITY TYPE:	740
ADDRESS:	5200 YERBA BUENA		TELEPHONE:	(707) 539-6780
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 6		CENSUS: 6	DATE:	08/21/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caregiver, Marbella Matos Administrator, Angelica Martinez		TIME COMPLETED:	03:00 PM

SUPERVISORS NAME: Hope DeBenedetti LICENSING EVALUATOR NAME: Farhaan Sarangi LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023

Link to Parent Document Below:

FACILITY NAME: YERBA BUENA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496801807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/22/2023 Section Cited CCR 87202(a)	1 2 3 4 5 6 7	87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.	1 2 3 4 5 6 7	Plan of Correction shall include caregivers to vacate the property in the back. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the inspection from the LPAs, Assistant Fire Marshall and the Senior Code Enforcement Officer, it was determined that the structure in the back was not STD 850 fire clearance approved. This presents an immediate health, safety and personal rights risk to the residents in care. Civil Penalty Asssessed in the amount of $500.00.	8 9 10 11 12 13 14	Plan of Correction due on August 22, 2023.
Type A 08/22/2023 Section Cited CCR87207	1 2 3 4 5 6 7	87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.	1 2 3 4 5 6 7	Plan of Correction shall include that the Administrator conducts staff training regarding documents and retaining correct documents to be provided to licensing upon request. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Documents provided by the licensee were emailed on August 2, 2023 to the LPA reflecting a City of Santa Rosa Fire Department Inspection report that had falsified verbiage regarding the structure clearance	8 9 10 11 12 13 14	Plan of Correction due date August 28, 2023.

SUPERVISOR'S NAME: Hope DeBenedetti LICENSING EVALUATOR NAME: Farhaan Sarangi LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023